Version 2.69

87509-6Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 [CMS Assessment]Active

Term Description

This panel should be used for CMS LCDS v4.00 Admission assessments performed since July 1, 2018. The effective date of new versions of this form (e.g. v5.00) have been delayed due to the COVID-19 PHE. For the latest information, please see announcements on https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/LTCH-Quality-Reporting/LTCH-Quality-Reporting-Spotlight-Announcements.
Source: Regenstrief LOINC

Panel Hierarchy
Details for each LOINC in Panel LHC-Forms

LOINC Name R/O/C Cardinality Example UCUM Units
87509-6 Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00 [CMS Assessment]
Indent85636-9 Administrative Information
IndentIndent58198-3 Type of Record
IndentIndent54581-4 Facility Provider Numbers
IndentIndentIndent76468-8 National Provider Identifier (NPI)
IndentIndentIndent69417-4 CMS Certification Number (CCN)
IndentIndentIndent45398-5 State Medicaid Provider Number
IndentIndent85632-8 Type of Provider
IndentIndent54593-9 Assessment Reference Date. Observation end date {mm/dd/yyyy}
IndentIndent52455-3 Admission Date {mm/dd/yyyy}
IndentIndent52454-6 Reason for Assessment
IndentIndent85816-7 Patient Demographic Information
IndentIndentIndent54503-8 Legal Name of Patient
IndentIndentIndentIndent45392-8 First name
IndentIndentIndentIndent45393-6 Middle initial
IndentIndentIndentIndent45394-4 Last name
IndentIndentIndentIndent45395-1 Suffix
IndentIndentIndent45966-9 Social Security and Medicare Numbers
IndentIndentIndentIndent45396-9 Social Security Number
IndentIndentIndentIndent45397-7 Medicare number (or comparable railroad insurance number)
IndentIndentIndent45400-9 Medicaid Number
IndentIndentIndent46098-0 Gender
IndentIndentIndent21112-8 Birth Date {mm/dd/yyyy}
IndentIndentIndent59362-4 Race/Ethnicity 1..6
IndentIndentIndent54505-3 Language
IndentIndentIndentIndent54588-9 Does the patient need or want an interpreter to communicate with a doctor or health care staff?
IndentIndentIndentIndent54899-0 Preferred language
IndentIndentIndent45404-1 Marital Status
IndentIndentIndent52556-8 Payer Information 1..13
IndentIndent85815-9 Pre-Admission Service Use
IndentIndentIndent85398-6 Admitted From
Indent87215-0 Hearing, Speech, and Vision
IndentIndent45482-7 Comatose. Persistent vegetative state/no discernible consciousness
IndentIndent95737-3 Expression of Ideas and Wants
IndentIndent95740-7 Understanding Verbal and Non-Verbal Content
Indent95854-6 Cognitive Patterns
IndentIndent95852-0 Signs and Symptoms of Delirium (from CAM)
IndentIndentIndent95853-8 Acute Onset and Fluctuating Course
IndentIndentIndentIndent95813-2 Is there evidence of an acute change in mental status from the patient's baseline?
IndentIndentIndentIndent95855-3 Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go or increase and decrease in severity?
IndentIndentIndent95812-4 Inattention.Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?
IndentIndentIndent95814-0 Disorganized thinking.Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
IndentIndentIndent95856-1 Altered Level of Consciousness
IndentIndentIndentIndent95857-9 Overall, how would you rate the patient's level of consciousness? Alert (Normal)
IndentIndentIndentIndent95858-7 Overall, how would you rate the patient's level of consciousness? Vigilant (hyperalert) or Lethargic (drowsy, easily aroused) or Stupor (difficult to arouse) or Coma (unarousable)
Indent88238-1 Functional Abilities and Goals
IndentIndent85642-7 Prior Functioning: Everyday Activities
IndentIndentIndent85071-9 Indoor Mobility (Ambulation)
IndentIndent83234-5 Prior Device Use 1..4
IndentIndent95859-5 Self-Care - Admission Performance
IndentIndentIndent95019-6 Eating
IndentIndentIndent95018-8 Oral hygiene
IndentIndentIndent95017-0 Toileting hygiene
IndentIndentIndent95016-2 Wash upper body
IndentIndent95860-3 Self-Care - Discharge Goal
IndentIndentIndent89409-7 Eating
IndentIndentIndent89404-8 Oral hygiene
IndentIndentIndent89389-1 Toileting hygiene
IndentIndentIndent96098-9 Wash upper body
IndentIndent87502-1 Mobility - Admission Performance
IndentIndentIndent95011-3 Roll left and right
IndentIndentIndent95010-5 Sit to lying
IndentIndentIndent95009-7 Lying to sitting on side of bed
IndentIndentIndent95008-9 Sit to stand
IndentIndentIndent95007-1 Chair/bed-to-chair transfer
IndentIndentIndent95006-3 Toilet transfer
IndentIndentIndent95004-8 Walk 10 feet
IndentIndentIndent95003-0 Walk 50 feet with two turns
IndentIndentIndent95002-2 Walk 150 feet
IndentIndentIndent95738-1 Does the patient use a wheelchair and/or scooter?
IndentIndentIndent94992-5 Wheel 50 feet with two turns
IndentIndentIndent95739-9 Indicate the type of wheelchair or scooter used
IndentIndentIndent94991-7 Wheel 150 feet
IndentIndentIndent95739-9 Indicate the type of wheelchair or scooter used
IndentIndent95862-9 Mobility - Discharge Goal
IndentIndentIndent89398-2 Roll left and right
IndentIndentIndent89394-1 Sit to lying
IndentIndentIndent85927-2 Lying to sitting on side of bed
IndentIndentIndent89392-5 Sit to stand
IndentIndentIndent89414-7 Chair/bed-to-chair transfer
IndentIndentIndent89390-9 Toilet transfer
IndentIndentIndent89385-9 Walk 10 feet
IndentIndentIndent89381-8 Walk 50 feet with two turns
IndentIndentIndent89383-4 Walk 150 feet
IndentIndentIndent89375-0 Wheel 50 feet with two turns
IndentIndentIndent89377-6 Wheel 150 feet
Indent95733-2 Bladder and Bowel
IndentIndent95735-7 Bladder Continence
IndentIndent95736-5 Bowel Continence
Indent95864-5 Active Diagnoses
IndentIndent89045-9 Indicate the patient's primary medical condition category
IndentIndent52797-8 Other medical condition
IndentIndent83243-6 Comorbidities and Co-existing Conditions 1..33
Indent95865-2 Swallowing/Nutritional Status
IndentIndent54567-3 Height and Weight
IndentIndentIndent3137-7 Height (in inches) [in_us];cm;m
IndentIndentIndent3141-9 Weight (in pounds) [lb_av];kg
Indent85055-2 Skin Conditions
IndentIndent58214-8 Unhealed Pressure Ulcers/Injuries. Does this patient have one or more unhealed pressure ulcers/injuries?
IndentIndent83246-9 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
IndentIndentIndent54884-2 Number of Stage 1 pressure injuries {#}
IndentIndentIndent55124-2 Number of Stage 2 pressure ulcers {#}
IndentIndentIndent55125-9 Number of Stage 3 pressure ulcers {#}
IndentIndentIndent55126-7 Number of Stage 4 pressure ulcers {#}
IndentIndentIndent54893-3 Number of unstageable pressure ulcers/injuries due to non-removable dressing/device {#}
IndentIndentIndent54946-9 Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar {#}
IndentIndentIndent54950-1 Number of unstageable pressure injuries presenting as deep tissue injury {#}
Indent87521-1 Medications
IndentIndent57255-2 Drug Regimen Review: Did a complete drug regimen review identify potential clinically significant medication issues?
IndentIndent57281-8 Medication Follow-up: Did the facility contact a physician (or physician-designee) by midnight of the next calendar day and complete prescribed/recommended actions in response to the identified potential clinically significant medication issues?
Indent87230-9 Special Treatments, Procedures, and Programs
IndentIndent83252-7 Special Treatments, Procedures, and Programs 1..6
IndentIndent87537-7 Spontaneous Breathing Trial (SBT) (including Tracheostomy Collar or Continuous Positive Airway Pressure (CPAP) Breathing Trial) by Day 2 of the LTCH Stay
IndentIndentIndent87539-3 Invasive Mechanical Ventilation Support upon Admission to the LTCH
IndentIndentIndent87538-5 Assessed for readiness for SBT by day 2 of the LTCH stay
IndentIndentIndent87540-1 Deemed medically ready for SBT by day 2 of the LTCH stay
IndentIndentIndent87541-9 Is there documentation of reason(s) in the patient's medical record that the patient was deemed medically unready for SBT by day 2 of the LTCH stay?
IndentIndentIndent87542-7 SBT performed by day 2 of the LTCH stay
IndentIndent69339-0 Influenza Vaccine
IndentIndentIndent55019-4 Did the patient receive the influenza vaccine in this facility for this year's influenza vaccination season?
IndentIndentIndent58131-4 Date influenza vaccine received {mm/dd/yyyy}
IndentIndentIndent55020-2 If influenza vaccine not received, state reason: C

Fully-Specified Name

Long-Term Care Hospital (LTCH) Continuity Assessment Record and Evaluation (CARE) Data Set (LCDS) - Admission - version 4.00
CMS Assessment

Basic Attributes

First Released
Version 2.63
Last Updated
Version 2.69
Order vs. Observation
Panel Type

LOINC FHIR® API Example - CodeSystem Request Get Info